Der Nervenarzt

, 82:431

Intensivmedizinische Versorgung von Patienten mit intrazerebraler Blutung

  • J. Diedler
  • M. Sykora
  • C. Herweh
  • B. Orakcioglu
  • K. Zweckberger
  • T. Steiner
  • W. Hacke
Übersichten

Zusammenfassung

Etwa 10–15% aller Schlaganfälle werden durch eine nichtaneurysmatische intrazerebrale Blutung (ICB) verursacht. Aufgrund der Altersstruktur der Bevölkerung ist von einer steigenden Inzidenz auszugehen. Die Mortalität wird in Arbeiten aus den 1990er Jahren auf bis zu 50% geschätzt. Es ist jedoch zu vermuten, dass die schlechte Prognose durch eine „sich selbst erfüllende Prophezeiung“ mitbedingt ist, im Rahmen derer Patienten mit ICB häufig nur eine palliative Therapie erhalten. Eine neuere Studie zeigte, dass alleine die Behandlung auf einer spezialisierten neurologischen Intensivstation mit einer Reduktion der Mortalität assoziiert war. In den letzten Jahren wurden erhebliche Anstrengungen unternommen, Therapiekonzepte für die intrazerebrale Blutung zu entwickeln und in randomisierten Studien zu prüfen. Neben dem neurologischen Status bei Aufnahme ist das Blutungsvolumen ein entscheidender prognostischer Faktor, und die rasche Eingrenzung der Blutung wurde als wichtiger therapeutischer Ansatz identifiziert. Im Anschluss an eine vielversprechende Dosisfindungsstudie zeigte eine Phase-III-Studie zwar eine Verringerung der Hämatomzunahme nach Gabe von aktiviertem Faktor VIIa innerhalb der ersten 4 h, ein signifikanter Effekt auf das klinische Outcome konnte jedoch nicht nachgewiesen werden. Ähnliche Ergebnisse fanden sich in einer randomisierten Studie zur Blutdrucksenkung in der Akutphase. Der Beleg aus randomisierten Studien, dass eine Verminderung des Hämatomwachstums sich in einer relevanten Verbesserung des Outcomes niederschlägt, steht somit weiterhin aus. Auch der Wert der chirurgischen Therapie ist nicht abschließend geklärt. In der bisher größten randomisierten Studie schien nur eine kleine Subgruppe der Patienten mit oberflächlich gelegener Blutung von der Ausräumung des Hämatoms zu profitieren. Diese Subgruppe wird derzeit in einer Nachfolgestudie untersucht. Ob die verbesserte intensivmedizinische Versorgung auch das funktionelle Outcome nachhaltig positiv beeinflusst, werden Daten der kommenden Jahre zeigen.

Schlüsselwörter

Intrazerebrale Blutung Therapie Intensivmedizin Prognostische Faktoren Verminderung des Hämatomwachstums 

Intensive medical care of patients with intracerebral hemorrhaging

Summary

Approximately 10–15% of acute strokes are caused by non-aneurysmatic intracerebral hemorrhage (ICH) and incidences are expected to increase due to an aging population. Studies from the 1990s estimated mortality of ICH to be as high as 50%. However, these figures may partly be attributed to the fact that patients suffering from ICH frequently received only supportive therapy and the poor prognosis may therefore be more a self-fulfilling prophecy. Recently it has been shown that treatment in a specialized neurological intensive care unit alone was associated with better outcomes after ICH. In recent years considerable efforts have been undertaken in order to develop new therapies for ICH and to assess them in randomized controlled trials. Apart from admission status, hemorrhage volume is considered to be the main prognostic factor and impeding the spread of the hematoma is thus a basic therapeutic principle. The use of activated factor VIIa (aFVIIa) to stop hematoma enlargement has been assessed in two large randomized controlled trials, however the promising results of the dose-finding study could not be confirmed in a phase III trial. Although hemostatic therapy with aFVIIa reduced growth of the hematoma it failed to improve clinical outcome. Similar results were found in a randomized controlled trial on blood pressure management in acute ICH. The link between reduction of hematoma growth and improved outcome is therefore still lacking. Likewise the value of surgical hematoma evacuation remains uncertain. In the largest randomized controlled trial on surgical treatment in ICH so far, only a small subgroup of patients with superficial hemorrhages seemed to benefit from hematoma evacuation. Whether improved intensive care can contribute to improved outcome after ICH will be shown by data obtained in the coming years.

Keywords

Intracerebral hemorrhage Treatment Intensive care Prognostic factors Impedance of hematoma growth 

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Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • J. Diedler
    • 1
  • M. Sykora
    • 1
    • 4
  • C. Herweh
    • 2
  • B. Orakcioglu
    • 3
  • K. Zweckberger
    • 3
  • T. Steiner
    • 1
  • W. Hacke
    • 1
  1. 1.Neurologische KlinikRuprecht-Karls-Universität HeidelbergHeidelbergDeutschland
  2. 2.Neuroradiologische UniversitätsklinikHeidelbergDeutschland
  3. 3.Neurochirurgische UniversitätsklinikHeidelbergDeutschland
  4. 4.Neurologische UniversitätsklinikComenius Universität BratislavaBratislavaSlowakei

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